HomeMy WebLinkAboutBLDP&G-17-006112 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=_Lf=; CITY ,a,;41aa MA` DATE _,23 --/� PERMIT# f,�l-�/?-1 --ek)�i1/g
JOBS E ADDRESS "/ ,- .2P /�y4P.P/,1a OWNERS NAME
POWNER ADDRESS s2% 1R` $ P/ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL IA---- EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED; YES❑ NO❑
FIXTURES 1- FLOOR—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM ,---
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM T—
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER _
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY • 14Y `w ?fill
ROOF DRAIN '
SHOWER STALL (` f k -?('1I
\ -
SERVICE I MOP SINK �✓
TOILET _
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0" NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY N/� OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
';; CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. --- /�i/l !fir
PLUMBER'S NAME_'-'7 % 6k/i-v LICENSE# �`�'�°y SIG • 'IRE
MP JP❑ CORPORATION E'# 32 7 ' PARTNERSHIP❑.# LLC❑#
COMPANY NAME l//del,i,74, 1�H c ADDRESS t/ C"01.'' 's rr
CITY itt, W-4,c i STATE / � ZIP a2�77 TEL
i / I
FAX CELL777/- f 0 `71� EMAIL lam' -i,�t- 1-?7(rS�C) QdC- LAC"'i
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
e`f'rroi PERMIT# /1"/-� CV 61/
`�ki�_, s CITY "icir/VA9,"( h4�, DATE ��.�' F t� ' -I.�
JOBSITE ADDRESS -W f'r ui../-e 28 —1✓' '?rfirlotr OWNERS NAME
OWNER ADDRESS Sfe/"' W I i2c l / �/% TEL FAX
TYPE O+ OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLYNEW:❑ RENOVATION: ] REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLI.H.NCES FLOORS—I 9SM 1 2 3 4 5 6 7 8 9 10 '1'1 12 13 I 1J
BOILER
BOOSTER
CONVERSION BURNER _
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
•
INFRARED HEATER
LABORATORY COCKS er 1
MAKEUP AIR UNIT
OVEN q t,
POOL HEATER C f{
ROOM!SPACE HEATER T�
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [ fiSIO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
t.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledl
`— and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME , . 6a 6", e LICENSE# SIGNAT
MP MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION[lam 3Zy' PARTNERSHIP❑# LLC❑
COMPANY NAME f/ecqr4:3, c' e _ ADDRESS 1? efe''/J/
CITY STATE - 1, ZIP Z faa 7 7 TEL
FAX CELL 7?'7 3 -a7?`li EMAIL 6ei'i.1K7ea C- l �
9 � �